EZNET Total Access
848 4th Ave. 3rd Floor
Huntington, WV 25701
Email: info@ezwv.com
Fax: (304) 525-3772 Date:___________________
NAME:_______________________________________________________________________
COMPANY NAME:_______________________________________________________________
ADDRESS:____________________________________________________________________
CITY:_______________________________________________________________________
ZIP CODE:______________________________ STATE:_____________________________
PHONE:_________________________________ EMAIL:_____________________________
FAX:___________________________________
What is the best way to contact you? ___ Phone ___Email
What is the nature of your business?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Is your company currently using the Internet? ___ yes ___no
Who is your current Internet Provider?
____________________________________________________________________________
How many dial-up connections do you have?
____________________________________________________________________________
Do you have a dedicated high speed connection? ___ yes ___no
What type of access are you using?
___ ISDN ___ Wireless ___ Frame Relay ___ Full T1 ___ Other
What type of CSU/DSU are you using?
Make:_________________________________ Model:_____________________________
What type of Router are you using?
Make:_________________________________ Model:_____________________________
Do you have a LAN? ___ yes ___no
What type of Network Operating System are you using?
___ Novel ___ Lantistic ___ Windows
___ Unix ___ NT ___ Other
Is your LAN TCP/IP compliant? ___ yes ___no
Do you have a Domain Name? If yes, what is the address?
____________________________________________________________________________
Do you have a Web Site? ___ yes ___no
Where is it currently being hosted?
____________________________________________________________________________
Who would be involved in the decision making process?
____________________________________________________________________________
Do you have a budget for this site/project? ___ yes ___no
What is your time-frame/deadline for this project?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Please list any additional information that you feel may be useful in
assessing your needs or concerns you have about this project, etc.
____________________________________________________________________________
____________________________________________________________________________
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